Screening Instruments
CAGE Questionnaire Alcohol
Have you ever felt you should cut down on your drinking?
Have people annoyed you by criticising your drinking?
Have you ever felt bad or guilty about your drinking?
Have you ever had a drink first thing in the morning to steady nerves or get over a hangover?
Score: 1 point per YES. Score ≥2 is clinically significant and indicates probable alcohol dependence. Sensitivity ~85%, specificity ~90%.
AUDIT-C Brief 3-item
| Question | Scoring |
|---|---|
| How often do you drink? | Never=0, Monthly=1, 2-4x/mo=2, 2-3x/wk=3, 4+/wk=4 |
| Drinks per typical day? | 1-2=0, 3-4=1, 5-6=2, 7-9=3, 10+=4 |
| 6+ drinks on one occasion? | Never=0, <Monthly=1, Monthly=2, Weekly=3, Daily=4 |
Positive screen: ≥3 (women) / ≥4 (men). Maximum score: 12. Higher scores = greater likelihood of harmful use.
FAST Alcohol Screening 4-item
- F — Frequency: 8+ units on occasion ≥monthly?
- A — Alcohol-related failure in roles?
- S — Someone expressed concern?
- T — Taken a drink in the morning?
If F=Never: screen negative. If F=Daily/almost daily: screen positive. Otherwise score all 4 items. ≥3 = positive.
DAST-10 Drug Use
Drug Abuse Screening Test — past 12 months (exclude alcohol/tobacco)
- Have you used drugs other than for medical reasons?
- Do you abuse more than one drug at a time?
- Are you always able to stop when you want?
- Have you had blackouts or flashbacks?
- Do you ever feel bad or guilty about your drug use?
- Does your partner/family ever complain?
- Have you neglected family due to drug use?
- Have you engaged in illegal activities to obtain drugs?
- Have you experienced withdrawal symptoms?
- Have you had medical problems (e.g. memory loss, hepatitis)?
Interpretation: 0=None; 1-2=Low; 3-5=Moderate; 6-8=Substantial; 9-10=Severe
FRAMES — Brief Intervention
Personalised feedback on risk/harm
Emphasise personal choice and responsibility
Clear advice to change behaviour
Range of options for change offered
Warm, reflective, non-judgmental style
Reinforce belief in ability to change
Motivational Interviewing — Stages of Change (Prochaska & DiClemente)
MI Core Skills (OARS)
- O — Open questions
- A — Affirmations
- R — Reflective listening
- S — Summaries
Nursing Role in MI
- Develop discrepancy between current behaviour and goals
- Roll with resistance — never confront directly
- Match intervention to readiness stage
- Avoid labelling (don't say "addict" / "alcoholic")
Withdrawal Severity Scales
| Domain | Scale | Clinical Notes |
|---|---|---|
| Nausea / Vomiting | 0–7 | 0=none; 4=intermittent nausea; 7=constant nausea, dry heaves |
| Tremor | 0–7 | 0=none; 4=moderate with arms extended; 7=severe even at rest |
| Paroxysmal Sweats | 0–7 | 0=none; 4=beads of sweat; 7=drenching sweats |
| Anxiety | 0–7 | 0=none; 4=moderately anxious; 7=panic state |
| Agitation | 0–7 | 0=normal; 4=moderately fidgety; 7=paces/thrashes |
| Tactile disturbances | 0–7 | Itching, bugs crawling, burning sensation |
| Auditory disturbances | 0–7 | Tinnitus to auditory hallucinations |
| Visual disturbances | 0–7 | Photosensitivity to visual hallucinations |
| Headache | 0–7 | 0=none; 7=extremely severe, fullness in head |
| Orientation | 0–4 | 0=oriented; 2=unsure of date; 4=disoriented to person/place |
| Total: 0–67 | Mild <10 | Moderate 10–19 | Severe ≥20 | |
Monitoring frequency: Mild: 4-hourly. Moderate: 2-hourly. Severe/≥20: Hourly. Score ≥15 = consider IV diazepam. Score ≥20 = HDU/ICU level care.
COWS — Clinical Opiate Withdrawal Scale
11 items; total score guides buprenorphine induction
| Item | Max Score |
|---|---|
| Resting pulse rate | 4 |
| Sweating | 4 |
| Restlessness | 5 |
| Pupil size | 5 |
| Bone/joint aches | 4 |
| Runny nose / tearing | 4 |
| GI upset | 5 |
| Tremor | 4 |
| Yawning | 4 |
| Anxiety / irritability | 4 |
| Gooseflesh skin | 5 |
| Total | 48 |
5–12=Mild | 13–24=Moderate | 25–36=Moderately severe | >36=Severe. Buprenorphine induction requires COWS ≥8–12 to avoid precipitated withdrawal.
Urine Drug Screening — Key Points
| Substance | Detection Window |
|---|---|
| Alcohol | 12–24 hours (EtG up to 80h) |
| Cannabis (single use) | 3 days |
| Cannabis (heavy use) | Up to 30 days |
| Cocaine metabolites | 2–4 days |
| Opioids (heroin) | 2–3 days |
| Methadone | 3–5 days |
| Benzodiazepines | 7 days (up to 30 long-acting) |
| Amphetamines | 2–4 days |
Note: Poppy seeds can cause false-positive opioid results. Confirm positives with GC-MS. Chain of custody essential for legal/employment screens.
Alcohol Dependence — Key Concepts
Physical vs Psychological Dependence
| Feature | Physical | Psychological |
|---|---|---|
| Tolerance | Yes — neuroadaptation | Yes — behavioural |
| Withdrawal | Yes — autonomic | Cravings, anxiety |
| Mechanism | GABA/glutamate imbalance | Reward pathway (dopamine) |
| Treatment focus | Medically assisted detox | Psychological therapies |
UK Alcohol Units
1 unit = 8g (10ml) pure ethanol
- Single pub measure spirits (25ml/40%) = 1 unit
- Small glass wine 125ml (12%) = 1.5 units
- Pint beer 4% = 2.3 units
- Can 500ml beer 5% = 2.5 units
Safe limits: ≤14 units/week for both sexes; spread over ≥3 days; 2 drink-free days/week
Alcohol-Related Conditions
Wernicke's Encephalopathy — TRIAD:
- Ophthalmoplegia — lateral gaze palsy, nystagmus
- Ataxia — cerebellar gait disturbance
- Confusion — global confusional state
Cause: Thiamine (B1) deficiency. Only 1/3 have full triad. NEVER give glucose before thiamine (IV Pabrinex) — precipitates Wernicke's
Korsakoff's Psychosis: Anterograde amnesia, confabulation, personality change. Chronic thiamine deficiency. Often irreversible.
Other conditions: Alcoholic hepatitis (AST:ALT >2:1), cirrhosis, pancreatitis (acute/chronic), peripheral neuropathy, cardiomyopathy (dilated), Mallory-Weiss tears, oesophageal varices, fetal alcohol syndrome
Alcohol Withdrawal Timeline
Detoxification Protocols
Fixed-Dose Regimen (Community/Low-Risk)
| Day | Dose | Frequency |
|---|---|---|
| 1–2 | 20–30 mg | QDS (four times daily) |
| 3–4 | 15 mg | QDS |
| 5 | 10 mg | QDS |
| 6 | 10 mg | BD |
| 7 | 10 mg | Nocte |
Symptom-Triggered (Inpatient — CIWA-guided)
| CIWA Score | Action |
|---|---|
| <8 | Monitor 4-hourly, no medication |
| 8–14 | Chlordiazepoxide 10–20 mg PRN |
| 15–19 | Chlordiazepoxide 20–30 mg, review hourly |
| ≥20 | IV diazepam, HDU transfer, senior review |
Nursing Caution: Monitor for respiratory depression, especially in elderly or with hepatic impairment. Diazepam preferred in severe withdrawal (IV available). Lorazepam preferred if severe hepatic failure (no active metabolites).
IV Pabrinex (Thiamine): Pair 1 (250mg thiamine/3.5mg B2/160mg B6) + Pair 2 (500mg vitamin C/160mg nicotinamide). Dilute in 100ml NaCl 0.9%, infuse over 30 min. Give TDS for 3–5 days if Wernicke's suspected. Oral thiamine 100mg TDS thereafter. Anaphylaxis kit must be available.
Relapse Prevention Medications
| Drug | Mechanism | Dosing | Key Points |
|---|---|---|---|
| Acamprosate | GABA agonist / glutamate antagonist — reduces craving | 666mg TDS (after detox) | Start after detox; renally cleared; safe in liver disease; no interaction with alcohol |
| Naltrexone | Opioid antagonist — blocks reward of alcohol | 50mg OD | Hepatotoxic in high doses; must be opioid-free ≥7–10 days before starting; also used in opioid dependence |
| Disulfiram | Aldehyde dehydrogenase inhibitor — aversive reaction | 200mg OD | Reaction: flushing, vomiting, palpitations, hypotension. Requires supervision. Contraindicated: CVD, psychosis, pregnancy. |
Alcohol Withdrawal Risk Calculator (CIWA-Ar)
Opioid Use Disorder
Opioid Dependence Features
- Tolerance: Increasing dose needed for same effect
- Physical dependence: Withdrawal on cessation
- Psychological dependence: Compulsive use despite harm
- Salience: Drug-seeking dominates life
- Pinpoint pupils (miosis) on intoxication
- Dilated pupils (mydriasis) in withdrawal
Opioid Withdrawal Symptoms
Early (6–24h): Yawning, lacrimation, rhinorrhoea, anxiety, restlessness, diaphoresis
Late (24–72h): Vomiting, diarrhoea, abdominal cramps, gooseflesh, insomnia, myalgia, piloerection
Heroin withdrawal: peaks 36–72h, resolves 7–10 days. Methadone withdrawal: peaks 3–5 days, prolonged (2–3 weeks). Rarely life-threatening — unlike alcohol withdrawal.
Opioid Overdose Recognition & Response
Naloxone (Narcan) Administration
- IV: 400 micrograms IV; repeat every 2–3 min; max 10mg
- IM: 400 micrograms IM if no IV access
- Intranasal (Nyxoid): 1.8mg per nostril — for carers/lay use
- Half-life shorter than opioids — re-sedation possible; observe 1–2 hours minimum
- Can precipitate acute withdrawal — agitation, vomiting, seizures
Take-home naloxone: Prescribed to opioid users and their carers. Training includes: signs of overdose, recovery position, calling 999, intranasal/IM technique. Available at pharmacies and community drug services in UK.
Opioid Substitution Therapy (OST)
| Feature | Methadone | Buprenorphine/Naloxone (Suboxone) |
|---|---|---|
| Drug type | Full mu-opioid agonist | Partial agonist / opioid antagonist |
| Formulation | Oral liquid (1mg/ml, green) | Sublingual film/tablet |
| Starting dose | 10–30mg (max 30mg day 1) | 4–8mg (COWS ≥8 before first dose) |
| Maintenance dose | 60–120mg OD (optimal) | 12–24mg OD (range 4–32mg) |
| Overdose risk | High — respiratory depression | Low — ceiling effect on respiratory depression |
| Diversion potential | High (liquid form) | Lower (naloxone precipitates withdrawal if injected) |
| QTc prolongation | Yes — dose-dependent, monitor ECG | Minimal |
| Drug interactions | Benzodiazepines, alcohol, CNS depressants — HIGH RISK | Less significant interactions |
| Precipitated withdrawal? | No | YES — if given too soon after last opioid use |
| Driving | Restricted — inform DVLA, may require assessment | Restricted — same rules apply |
| Supervised consumption | Daily supervised swallow — pharmacy | May be less restricted |
| Pregnancy | Drug of choice (fetal monitoring) | Second-line (evidence growing) |
| Hepatic impairment | Use with caution | Use with caution; avoid severe hepatitis |
Precipitated Withdrawal Risk with Buprenorphine: Buprenorphine displaces other opioids from receptors but has partial agonist activity. If given while other opioids still active = sudden, severe withdrawal. Ensure COWS ≥8–12 before first buprenorphine dose.
Methadone — Nursing Considerations
Dangerous interactions:
- Benzodiazepines + Methadone = respiratory depression/death
- Alcohol + Methadone = CNS depression
- Rifampicin/phenytoin = reduce methadone levels (enzyme inducers)
- Erythromycin/fluconazole = increase methadone levels (inhibitors)
QTc monitoring: Baseline ECG. Repeat at 30mg, 50mg, 100mg+. Withold if QTc >500ms. Caution >450ms. Additive with other QTc-prolonging drugs (antipsychotics, some antibiotics).
Harm Reduction Services
- Needle/syringe exchange: Clean injecting equipment reduces HIV/HCV transmission
- Safe injecting guidance: Vein care, not sharing equipment, clean water
- Naloxone provision: Take-home and training for users and families
- Drug consumption rooms: Supervised use (controversial; evidence-based)
- Wound care: Abscess management, skin care for IVDU
- Testing: HCV, HIV, hepatitis B (offer vaccination), STI screening
- Safe sex: Condom provision, contraceptive advice
- Housing & social support as part of treatment
Blood-Borne Virus Screening (IVDU)
| Virus | Prevalence IVDU | Action |
|---|---|---|
| Hepatitis C (HCV) | ~50% in chronic IVDU | RNA test, treat with DAAs (cure rate >95%) |
| HIV | Varies by region | 4th gen test, refer for ART |
| Hepatitis B (HBV) | High risk | Vaccinate if non-immune; treat if chronic |
UK Supervised Injectable Heroin (Heroin-Assisted Treatment / HAT): Diamorphine (pharmaceutical heroin) prescribed to long-term heroin users who have not responded to oral OST. Administered under strict clinical supervision. Evidence shows reduction in street heroin use, crime, and improved social outcomes. Limited to specific licensed centres (UK only).
Benzodiazepine Dependence
Long-Term Therapeutic Use Dependence
Dependence can develop within 4–6 weeks of regular use at therapeutic doses. Often prescribed for anxiety/insomnia. Withdrawal can be life-threatening (seizures).
Ashton Manual approach:
- Switch to diazepam equivalent (long half-life, smoother reduction)
- Reduce by no more than 10% of current dose every 2–4 weeks
- Tapers can take months to years for long-term users
- Never abrupt cessation — seizure risk
Diazepam Equivalents
| Benzodiazepine | Equivalent to 5mg Diazepam |
|---|---|
| Alprazolam (Xanax) | 0.25 mg |
| Lorazepam (Ativan) | 0.5 mg |
| Oxazepam | 10 mg |
| Clonazepam | 0.25 mg |
| Temazepam | 10 mg |
| Nitrazepam | 5 mg |
| Chlordiazepoxide | 25 mg |
Benzodiazepine Withdrawal Syndrome
Danger: Can be fatal — seizures and DT-equivalent state possible
Symptoms: Anxiety, insomnia, tremor, sweating, nausea, hallucinations, depersonalisation, hyperacusis, photophobia, seizures (especially high-dose abrupt cessation)
Timing: Short-acting (lorazepam): 1–2 days. Long-acting (diazepam): 3–7 days. Protracted withdrawal symptoms (PAWS) can last months.
Z-Drug Dependence
Zopiclone / Zolpidem: Non-benzodiazepine hypnotics. Similar dependence potential to benzodiazepines. Same gradual withdrawal approach. Zopiclone = ~7.5mg equivalent to diazepam 5mg approx.
CNS Depression Triad — Critical Warning
Stimulant Use Disorders
Cocaine
Mechanism: Blocks dopamine/noradrenaline/serotonin reuptake. Short half-life (45–90 min). Crack cocaine smoked — faster onset/more intense.
Cardiovascular Emergencies
- Acute MI: Coronary artery spasm + thrombosis. Can occur in young adults with normal coronaries. ECG: ST elevation mimicking STEMI.
- Arrhythmia: VT, VF — sodium channel blockade
- Hypertensive crisis: Severe hypertension, stroke risk
- Aortic dissection: Severe hypertension + cocaine
Treatment note: Avoid beta-blockers in cocaine-induced chest pain (unopposed alpha causes vasoconstriction). Use nitrates/benzodiazepines/phentolamine.
Psychiatric Effects
Paranoid psychosis: Resembles paranoid schizophrenia. Tactile hallucinations ("cocaine bugs"/formication). Usually resolves with abstinence. Antipsychotics if severe.
Amphetamines / Methamphetamine
Mechanism: Releases dopamine, noradrenaline, serotonin + blocks reuptake. Crystal meth: far more potent. Effects last 8–12 hours.
Medical emergencies: Hyperthermia, rhabdomyolysis, renal failure, intracranial haemorrhage, cardiomyopathy, psychosis. Hyperthermia is primary cause of death — cooling essential.
MDMA (Ecstasy)
Serotonin syndrome risk: With SSRIs/MAOIs. Hyponatraemia from excessive water intake (SIADH effect) — can be fatal. Hyperthermia, seizures. Management: cooling, IV fluids cautiously, benzodiazepines.
Stimulant Withdrawal
"Crash": Profound fatigue, hypersomnia, depression (dopamine depletion), increased appetite. No medical emergency but psychiatric risk (suicidal ideation). Supportive treatment, monitor mood.
Cannabis & Novel Psychoactive Substances
Cannabis
High-potency cannabis ("skunk"): THC content up to 30%+ vs traditional cannabis 5–10%. Rising psychosis risk — dose-dependent relationship. Daily high-potency use associated with 5x increased psychosis risk.
Cannabinoid Hyperemesis Syndrome (CHS): Cyclical severe vomiting, nausea, abdominal pain in chronic heavy users. Compulsion to take hot baths/showers (hallmark feature — temporarily relieves symptoms). Capsaicin cream effective. Only cure: cessation of cannabis.
Cannabis Use Disorder: Dependence in ~9% of users (higher with early/daily use). Withdrawal: anxiety, irritability, insomnia, appetite loss, sweating. No pharmacotherapy licensed; CBT effective.
Novel Psychoactive Substances (NPS)
"Legal highs" / Spice / Mephedrone: Designed to mimic effects of cannabis/stimulants but evade drug laws. Psychoactive Substances Act 2016 (UK) banned production/supply.
Synthetic cannabinoids (Spice): Full CB1 agonists — much more potent than cannabis. Severe agitation, psychosis, seizures, renal failure, cardiac arrest. Unpredictable toxicity batch-to-batch.
Management: Consult TOXBASE (UK) for NPS toxicity management. Supportive care, benzodiazepines for agitation/seizures, monitor ECG/renal function.
Khat (Qat)
Plant containing cathinone (stimulant). Chewed by Yemeni and East African communities. Legal in UK until 2014 (Class C since). Associated with cardiovascular effects, psychosis, insomnia, nutritional neglect. Socially embedded — culturally sensitive approach needed.
GHB/GBL
Narrow therapeutic index. Life-threatening withdrawal (similar to alcohol/benzo). Tolerance develops rapidly — withdrawal should be managed inpatient with baclofen or benzodiazepines under medical supervision.
Dual Diagnosis — Mental Illness & Substance Misuse
Common Comorbidities
- Alcohol use disorder + Depression (bidirectional)
- Opioid dependence + PTSD / trauma history
- Stimulant use + Bipolar disorder
- Cannabis + Psychosis / Schizophrenia
- Benzodiazepine dependence + Anxiety disorders
- Polysubstance use + Personality disorders (EUPD/BPD)
Treatment Models
| Model | Description | Limitation |
|---|---|---|
| Sequential | Treat one condition, then other | Perpetuates cycle; poor outcomes |
| Parallel | Mental health + addictions services separately | Poor coordination; falls through gaps |
| Integrated | Joint assessment/treatment — one team | Resource intensive — recommended best practice |
Trauma-Informed Care
ACE (Adverse Childhood Experiences) Score: Strong dose-response relationship — higher ACE score = greater risk of addiction, mental illness, suicide, chronic disease. 10 domains: physical/emotional/sexual abuse, neglect, household dysfunction.
Principles of Trauma-Informed Care:
- Safety — physical and emotional
- Trustworthiness and transparency
- Peer support
- Collaboration and mutuality
- Empowerment, voice and choice
- Cultural, historical and gender sensitivity
Nursing approach: Never ask "What is wrong with you?" — ask "What happened to you?" Understand substance use as coping mechanism, not moral failing.
Recovery Framework
Abstinence vs Harm Reduction
| Approach | Philosophy | Example |
|---|---|---|
| Abstinence-based | Total cessation as only acceptable goal | 12-step (AA/NA), therapeutic communities |
| Harm reduction | Reduce harms without requiring abstinence | OST, needle exchange, naloxone provision |
| Integrated | Individualised — both valid depending on person | SMART Recovery, person-centred care |
Peer Support
- AA (Alcoholics Anonymous): 12-step programme; spiritual framework; sponsor relationship; evidence for engagement and abstinence maintenance
- NA (Narcotics Anonymous): Same structure for drug users
- SMART Recovery: Cognitive-behavioural approach; non-12-step; evidence-based self-management tools
- Peer mentoring: Lived experience workers in treatment services
Recovery Capital Framework
Recovery capital = resources to support recovery:
- Human capital: Education, skills, health, resilience
- Social capital: Supportive relationships, family, community
- Physical capital: Housing, income, assets
- Cultural capital: Belonging, identity, values
Higher recovery capital = better outcomes. Address all domains in care planning.
Relapse Prevention
HALT: Common relapse triggers — Hungry, Angry, Lonely, Tired
Relapse prevention plan should include:
- Warning signs (internal/external cues)
- Coping strategies for cravings
- People to call in crisis
- Avoiding high-risk situations
- If lapse occurs: stop, seek help, don't catastrophise
Contingency Management
Vouchers/prizes for negative drug tests or treatment attendance. Evidence-based for stimulant (cocaine/meth) and cannabis use disorders where pharmacotherapy unavailable. NICE approved for alcohol.
Residential Rehabilitation
Intensive structured programme for people with severe dependence. Therapeutic community model. 12-week to 12-month programmes. Most effective with strong aftercare plan.
Community Drug & Alcohol Teams (CDAT/CDAS)
UK community services providing: OST prescribing, keyworker support, psychosocial interventions, harm reduction, liaison with social care/housing, employment support. Referral by GP or self-referral.
GCC Context — Legal & Cultural Framework
Alcohol Legal Status by Country
| Country | Status | Notes |
|---|---|---|
| Saudi Arabia | Prohibited | Total ban; criminalised; penalties include flogging/imprisonment |
| Kuwait | Prohibited | Total ban since 1965; no licensed venues |
| UAE | Restricted | Licensed venues/hotels; Muslims prohibited; legal for non-Muslims; Abu Dhabi — personal permit system |
| Qatar | Restricted | Licensed hotels/venues; 2023 reforms relaxed some restrictions |
| Bahrain | Limited access | Licensed outlets; most liberal GCC state; non-Muslims relatively free |
| Oman | Restricted | Licenced hotel venues; expats can import limited amounts |
Clinical implication: Patients presenting with alcohol-related harm may face criminal prosecution. Confidentiality and mandatory reporting obligations vary by jurisdiction. Nurses must know local legal requirements while maintaining therapeutic relationship.
Drug Laws & Trafficking
Prevalent Substance Issues in GCC
- Tramadol misuse: Widely misused across GCC; prescription-only but available illegally; opioid dependence developing; seized in large quantities at borders
- Benzodiazepine misuse: Rising prescription drug misuse; easy access via prescription shopping
- Khat (Qat): Prevalent in Yemeni/East African expatriate communities; legal status varies; associated with stimulant dependence, dental/nutritional harm
- Heroin/cocaine: Trafficking routes through GCC to Europe/Asia; increasing local use reported
- Cannabis: Most common illicit substance; NPS/"legal highs" increasingly seized
Cultural Considerations & Treatment Access
Barriers to Help-Seeking
- Cultural shame (Ayb): Substance misuse seen as moral/religious failing; family honour at risk if disclosed
- Fear of criminalisation: Seeking treatment may lead to arrest/deportation
- Religious stigma: Alcohol haram in Islam; substance use taboo subject
- Expatriate vulnerability: Visa sponsorship tied to employment — fear of job loss
- Language barriers: Limited Arabic-language resources for non-Arab expats
- Family denial: Family may conceal problem rather than seek help
Treatment Services in GCC
UAE — Anonymous Treatment: Federal Law No. 14/1995 and subsequent amendments allow voluntary, anonymous treatment for substance use disorders without criminal penalty in certain circumstances. Dubai Drug Policy: treatment vs punishment paradigm evolving.
National Rehabilitation Centre (NRC), Abu Dhabi: Dedicated addiction treatment centre. Evidence-based treatment including OST. Confidential treatment for UAE nationals.
DHA (Dubai Health Authority): Addiction medicine competencies include assessment, brief intervention, OST prescribing, withdrawal management. HAAD/DOH (Abu Dhabi): Similar competency frameworks. SCFHS (Saudi): Psychiatry/addiction nursing specialty competencies.
Culturally Competent Nursing Practice
Non-judgmental approach: Explore substance use as health issue, not moral failure. Understand religious/cultural context without imposing values.
Privacy & confidentiality: Particularly important in GCC context. Explain confidentiality limits clearly. Use professional interpreters, not family, for sensitive disclosures.
Family involvement: Collective family culture — engage family with patient consent. Family education about addiction as a health condition, not a character flaw.
DHA/DOH/SCFHS Exam Preparation
High-Yield Exam Topics
Screening tools:
- CAGE — 4 questions, ≥2 significant (alcohol)
- AUDIT-C — 3 items, ≥3(women)/≥4(men) positive
- DAST-10 — drug use, past 12 months
- CIWA-Ar — alcohol withdrawal, 0–67, ≥20 = severe
- COWS — opioid withdrawal, ≥8 before buprenorphine
Critical interventions to know:
- IV Pabrinex BEFORE glucose in alcohol-dependent patients
- CIWA-Ar ≥20 = HDU care + IV diazepam
- DTs: 48–72h, mortality 5–10% untreated
- Buprenorphine: precipitated withdrawal if given too early (COWS <8)
- Naloxone half-life shorter than opioids — monitor for re-sedation
- Avoid beta-blockers in cocaine-induced chest pain
Common Exam Scenarios
Scenario 1: Patient 48h after last drink — confused, hallucinating, diaphoretic, tachycardic. Answer: Delirium Tremens — emergency, CIWA-Ar, IV diazepam, IV Pabrinex, HDU.
Scenario 2: Heroin user on methadone 60mg presents confused, respiratory rate 8. Answer: Opioid toxicity (not just methadone — polydrug use). IV naloxone 400mcg, repeat 2–3 min, observe for re-sedation.
Scenario 3: Starting patient on buprenorphine — what assessment needed first? Answer: COWS score must be ≥8–12; last opioid use timing; confirm mild-moderate withdrawal present before first dose.
Scenario 4: Patient with alcoholic liver disease on methadone — most dangerous interaction? Answer: Benzodiazepines or alcohol + methadone = respiratory depression; also check QTc prolongation.
Quick Reference — Key Numbers
| Fact | Value / Answer |
|---|---|
| CAGE positive threshold | ≥2 out of 4 |
| UK safe alcohol limit (both sexes) | 14 units/week |
| 1 alcohol unit = ethanol content | 8g (10ml) pure ethanol |
| CIWA-Ar: mild/moderate/severe thresholds | <10 / 10–19 / ≥20 |
| Alcohol withdrawal seizures — peak timing | 12–24 hours after last drink |
| Delirium Tremens — peak timing | 48–72 hours after last drink |
| Wernicke's triad | Ophthalmoplegia, Ataxia, Confusion |
| COWS threshold for buprenorphine induction | ≥8–12 |
| Naloxone IV dose (adult) | 400 micrograms; repeat 2–3 min; max 10mg |
| Dual diagnosis comorbidity in psychiatric services | 50–70% |
| Stages of Change model (number of stages) | 6 (including relapse) |
| Methadone optimal maintenance dose | 60–120mg OD |
| Acamprosate dosing | 666mg TDS (after detox complete) |
| Cannabis detection window (heavy use) | Up to 30 days |
| CHS hot shower hallmark | Compulsion for hot baths/showers relieves vomiting |